Encopresis

It can be upsetting to see your child suffering from the constipation that can lead to encopresis. And the onset of constipation can be so insidious that parents do not realize that their child is having a problem. School-aged children go to the bathroom on their own, and it is natural for parents to assume everything is OK unless their child tells them otherwise.

Our physicians and nurse practitioners are experts in helping kids have regular bowel movements on the toilet. We’ve had years of experience treating kids just like yours. So take a deep breath and try not to worry — your child will be fine and you and your family will get through this difficult time.

Read on to learn more about encopresis and what it means for your child.

How does encopresis happen?

Constipated children have fewer bowel movements than normal, and their bowel movements can be hard, dry, difficult to pass and so large that they can often even block up the toilet. Here's a common scenario:

1. Your child's stool can become impacted (packed into her rectum and large intestine).
    
2. Her rectum and intestine become enlarged due to the retained stool.
    
3. Eventually, her rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) becomes dilated, losing its strength.
    
4. Stool can start to leak around the impacted stool, soiling your child's clothing.
    
5. As more and more stool collects, your child will be less and less able to hold it in, leading to accidents. Because of decreased sensitivity in your child’s rectum, she may not even be aware she’s had an accident until after it has occurred.

In kids who haven’t yet been toilet trained, struggling to hold in excess stool or the constipation that arises from refusing to have a bowel movement on the toilet can also lead to encopresis.

How many kids does it affect?

It’s difficult to say for certain because many cases of encopresis are not reported. There seems to be a stigma attached to this condition that prevents many parents from reaching out and talking to other parents whose children may have had the same problem.

We estimate that between 1 and 3 percent of kids have this problem at one time or another in childhood.

Which children develop encopresis?

Any child with chronic constipation may develop encopresis. Some of the situations that predispose your child to constipation include:

• eating a “junk-food” diet that is low in fiber
• painful bowel movements
• lack of exercise
• stress in the family, with friends or at school
• change in bathroom routine, such as when a child starts a new school year and bathroom breaks are less frequent
• being too busy playing to take time to use the bathroom

For children who have never been toilet trained and who refuse to have a bowel movement on the toilet, additional concerns apply:

• reluctance to use bathrooms at home or in public
• anxiety about using the toilet

What kind of problems might my child have?

Encopresis can cause your child to have both physical and emotional problems.

Physical problems

• Impacted (backed up) stool in her intestine can cause abdominal pain, a loss of appetite and stool accidents.
   
• Some children, especially girls, develop urinary tract and/or bladder infections.
   
• The enlarged bowel can push on the bladder causing urine accidents during the day or night.
   
• Rarely, other health problems may cause the chronic constipation that can lead to encopresis, including the following:
  • hypothyroidism
  • Hirschsprung's Disease
  • celiac disease
  • inflammatory bowel disease

Emotional problems

Your child might feel emotionally upset by soiling her clothes, leading to feelings of shame and embarrassment.

You, too, might feel guilt, shame and anger from your child’s encopresis. It’s very important to try not to communicate this to your child, as this may worsen her emotional state.

Is encopresis painful?

While encopresis itself isn’t usually painful (unless the leaking stool leads to a rash on your child’s skin), the constipation that leads to it may be.

Causes

There are two basic causes. At Children’s Hospital Boston, we first determine the cause and then treat your child appropriately.

• long-term constipation — Encopresis is usually due to chronic constipation, which can be easily overlooked in children. There’s often no clear cause of this constipation, although sometimes it does run in families.
   
• toilet refusal — A much smaller number of children were never toilet trained successfully to have bowel movements in the toilet, some due to refusing to use the toilet and others due to developmental issues.

It’s rare that a child has an underlying medical condition that causes encopresis, but we do consider these causes when we see your child.

Signs & Symptoms

Here are some signs that your child might have constipation that could lead to encopresis:

• large stools that block up the toilet
   
• involuntary bowel movements or needing to have a bowel movement with little or no warning, which may soil underwear when a child cannot get to the bathroom in time
   
• small, frequent bowel movements

Long-Term Outlook

Though it may seem as though your child will suffer from encopresis forever, this isn’t the case. The vast majority of kids (the possible exceptions being those who have an underlying medical issue) will stop having stool accidents and have regular bowel movements on the toilet.

The end result of treatment is the same for both causes of encopresis, but the way we get there is different.

• long-term constipation— We’ll help your child pass the impacted stool and then help keep stool soft so that it passes easily and doesn’t get backed up again. After about six months, your child’s intestine and rectum will shrink to their normal size and your child should be able to have normal bowel movements on his own without any medication or prompting.
   
• toilet refusal— These children will get a combination of medical (laxatives, stool softeners) and behavioral treatments to help them get more comfortable using the toilet for bowel movements.

So take a deep breath. We know this is a frustrating time, but we’ve seen many, many kids who’ve had this problem — and we’ve helped them (and their families) get through it.

Questions to Ask Your Doctor

You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

If your child is suffering from the constipation that leads to encopresis and you’ve set up an appointment, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling like you have the information you need.

Some questions you may want to ask include:

• Does encopresis go away on its own?
• What are our treatment options?
• Are these laxatives safe?
• What are some good positive reinforcement strategies?
• What can we do at home to help?
• Where can we go for further information?

Keep in mind that your doctor will want to ask you some questions, too. These can include:

• How long has your child had this problem?
• Has your child been toilet trained?
• Is there a history of encopresis in the family?
• What’s your child’s diet like?

FAQ

Q: What is encopresis?

A: Encopresis is another word for fecal soiling — or accidentally having a bowel movement.

Q: What causes encopresis?

A: There are two basic causes. At Children’s, we first determine the cause and then treat your child appropriately.

• Encopresis is usually due to chronic (long-term) constipation, which can be easily overlooked in children. There’s often no clear cause of this constipation, although sometimes it runs in families.

• A much smaller number of children were never toilet trained successfully to have bowel movements in the toilet, some due to refusing to use the toilet and others due to developmental issues.

It’s rare that a child has an underlying medical condition that causes encopresis, but we do consider these causes when we see your child.

Q: How does encopresis happen?

A: Constipated children have fewer bowel movements than normal, and their bowel movements can hard, dry, difficult to pass and so large that they can often even block up the toilet. Here's a common scenario:

1. Your child's stool can become impacted (packed into her rectum and large intestine).
    
2. Her rectum and intestine become enlarged due to the retained stool.
    
3. Eventually, her rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) becomes dilated, losing its strength.
    
4. Stool can start to leak around the impacted stool, soiling your child's clothing.
    
5. As more and more stool collects, your child will be less and less able to hold it in, leading to accidents.

Because of decreased sensitivity in your child’s rectum, she may not even be aware she’s had an accident until after it has occurred.

In kids who haven’t yet been toilet trained, struggling to hold in excess stool or the constipation that arises from refusing to have a bowel movement on the toilet can also lead to encopresis.

Q: What signs should I look for?

A: Here are some signs that your child might have constipation that could lead to encopresis:

• large stools that block up the toilet
   
• involuntary bowel movements — or needing to have a bowel movement with little or no warning — which may soil underwear when a child cannot get to the bathroom in time
   
• small, frequent bowel movements

Q: What kind of problems might my child have?

A: Encopresis can cause your child to have both physical and emotional problems.

Physical problems

• Impacted (backed up) stool in her intestine can cause abdominal pain, a loss of appetite and stool accidents.
   
• Some children, especially girls, develop urinary tract and/or bladder infections.
   
• The enlarged bowel can push on the bladder causing urine accidents during the day or night.
   
• Rarely, other health problems may cause the chronic constipation that can lead to encopresis, including the following:
  • hypothyroidism
  • Hirschsprung's Disease
  • celiac disease
  • inflammatory bowel disease

Emotional problems

• Your child might feel emotionally upset by soiling her clothes, leading to feelings of shame and embarrassment.
   
• You, too, might feel guilt, shame and anger from your child’s encopresis. It’s very important to try not to communicate this to your child, as this may worsen her emotional state.

Q: Is encopresis painful?

A: While the encopresis itself isn’t usually painful (unless the leaking stool leads to a rash on your child’s skin), the constipation that leads to it can be quite painful.

Q: How is encopresis diagnosed?

A: When you make an appointment at Children’s, we’ll start with a complete medical history where we’ll ask you whether your child is toilet trained or not. Then, a physician will give your child a thorough physical exam. Your child’s medical history and the initial exam give the doctor enough information to diagnose encopresis. Many children also have an abdominal x-ray to evaluate the amount of stool in the large intestine.

Q: How is encopresis treated?

A: Treatment for encopresis may include:

• using laxatives to help your child pass the impacted stool
• using medication to keep your child’s bowel movements soft so the stool will pass easily
• having your child sit on the toilet for five to ten minutes after breakfast and dinner

We may also prescribe enemas to help remove the impacted stool. An enema is a liquid that is placed in your child's rectum that helps loosen the hard, dry stool.

• We only use enemas when medically indicated and both the child and parents are comfortable.
• We do have other treatments, but sometimes enemas with other medications are the easiest and most efficacious.
• Do not give your child an enema without the approval of her physician.

Q: What happens after the impacted stool is passed?

A: After your child passes the stool, it’s important to develop a good routine to ensure that stool does not get backed up again. Because your child’s intestine and rectum will remain stretched (they go back to normal after about six months), your child may still have problems with leakage.

To reduce the number of soilings, have your child sit on the toilet two to three times a day for five to ten minutes, preferably shortly after a meal.

Q: What can we do to make sure my child doesn’t get constipated again?

A: Often, making changes in your child's diet will help her constipation. Consider the following suggestions:

• Increase the amount of fiber in her diet by:
  • adding more fruits and vegetables
  • adding more whole-grain cereals and breads (check nutritional labels on packages for foods that have more fiber)
     
• encourage your child to drink more fluids, especially water
   
• limit fast foods and junk foods that are usually high in fats and sugars; instead offer more well-balanced meals and snacks
   
• limit whole milk to 16 ounces a day for the child over 2 (but not eliminating milk altogether; children need the calcium and Vitamin D in milk to help their bones grow strong)
   
• serve your child's meals on a regular schedule
   
• serve breakfast early so your child does not have to rush off and miss the opportunity to have a bowel movement
   
• increase the amount of exercise your child gets
   
• If your child has a limited diet/sensory aversion, a fiber supplement can be helpful — these come in chewable tablets, a powder that you can mix in a drink and a gummy variety.

Q: What if my child’s encopresis is caused by toilet refusal?

A: We usually see children and their parents individually at first and most children quickly master using the toilet without anxiety. For those who have trouble, we have developed Toilet School, an educational program for both parents and children to help them with difficult toilet training.

• It’s a six-week program in which six kids — mostly 4-, 5- and 6-year-olds — come to class once a week for an hour to an hour and a half.
   
• Parents attend a separate class where they learn behavioral techniques designed to help their children master toilet use.

By graduation time in the sixth week, about sixty percent of the kids have successfully had a bowel movement on the toilet. The ones who haven’t get follow-up visits until they’re successful.

For more information about Toilet School, see the Research & Innovation section.

Q: What is the long-term outlook for my child?

A: Though it may seem as though your child will suffer from encopresis forever, this isn’t the case. The vast majority of kids (the possible exceptions being those who have an underlying medical issue) will stop having stool accidents and have regular bowel movements on the toilet.

The end result of treatment is the same for both causes of encopresis, but the way we get there is different.

• long-term constipation — We’ll help your child pass the impacted stool and then help keep stool soft so that it passes easily and doesn’t get backed up again. After about six months, your child’s intestine and rectum will shrink to their normal size and your child should be able to have normal bowel movements on his own without any medication or prompting.
   
• toilet refusal — These children will get a combination of medical (laxatives, stool softeners) and behavioral treatments to help them get more comfortable using the toilet for bowel movements.